MODULE 6: REPRODUCTIVE ENDOCRONOLOGY

TOPIC 3: NORMAL AND ABNORMAL UTERINE BLEEDING

Rationale: The occurrence of bleeding at times other than expected menses is common. Accurate
diagnosis of abnormal uterine bleeding is necessary for appropriate management.

Objectives: Intended Learning Outcomes that the student should be able to:
A. Define the normal menstrual cycle and describe its endocrinology and physiology
B. Define abnormal uterine bleeding
C. Describe the pathophysiology and identify etiologies of abnormal uterine bleeding
D. Describe the steps in the evaluation and initial management of abnormal uterine bleeding
E. Summarize medical and surgical management options for patients with abnormal uterine
bleeding.

NORMAL AND ABNORMAL UTERINE BLEEDING

Student Handout

CLINICAL CASE:

A 45-year-old G2P0020, LMP 21 days ago, presents with heavy menstrual bleeding. Prior to 6 months
ago her cycles came every 28-30 days, lasted for 6 days, and were associated with cramps that were
relieved by ibuprofen. In the last 6 months there has been a change with menses coming every 25-32
days, lasting 7-10 days and associated with cramps not relieved by ibuprofen, passing clots and using 2
boxes of maxi pads each cycle.

She is worried about losing her job if the bleeding is not better controlled. She denies dizziness, but
complains of feeling weak and fatigued. Her weight has not changed in the last year. She denies any
bleeding disorders or reproductive cancers in the family. She uses condoms for contraception. She takes
no daily medications and has no other medical problems. She is married and works in a factory.

On physical exam, BP=130/88; P= 100; Ht=5’6’; Wt=150 pounds. She appears pale.
Pelvic exam shows normal vulva, vagina and cervix: normal size, mildly tender, mobile uterus; non-
tender adnexae without palpable masses.

Lab Results
 Hgb: 9.0,
 HCT: 27%,
 HCG: negative,
 Endometrial biopsy:
 normal secretory endometrium,
 Pelvic ultrasound: heterogeneous myometrium,
 endometrial lining 1.4cm and irregular consistent with endometrial polyp
 normal ovaries.

Discussion Questions:
1. What possible etiologies could cause this patient’s bleeding?
2. Which of these etiologies is associated with anovulation?
3. Discuss the mechanism for anovulatory bleeding.
4. How can you tell if this patient is having ovulatory cycles?
5. What further tests would indicate if there was an anatomic problem?
6. Describe 3 possible medical and 2 possible surgical therapies.